Factors associated with evidence-based practice among registered nurses in Sweden : a national cross-sectional study

Background: Evidence-based practice (EBP) is emphasized to increase the quality of care and patient safety. EBP is often described as a process consisting of distinct activities including, formulating questions, searching for information, compiling the appraised information, implementing evidence, and evaluating the resulting practice. To increase registered nurses' (RNs') practice of EBP, variables associated with such activities need to be explored. The aim of the study was to examine individual and organizational factors associated with EBP activities among RNs 2 years post graduation. Methods: A cross-sectional design based on a national sample of RNs was used. Data were collected in 2007 from a cohort of RNs, included in the Swedish Longitudinal Analyses of Nursing Education/Employment study. The sample consisted of 1256 RNs (response rate 76%). Of these 987 RNs worked in healthcare at the time of the data collection. Data was self-reported and collected through annual postal surveys. EBP activities were measured using six single items along with instruments measuring individual and work-related variables. Data were analyzed using logistic regression models. Results: Associated factors were identified for all six EBP activities. Capability beliefs regarding EBP was a significant factor for all six activities (OR = 2.6 - 7.3). Working in the care of older people was associated with a high extent of practicing four activities (OR = 1.7 - 2.2). Supportive leadership and high collective efficacy were associated with practicing three activities (OR = 1.4 - 2.0). Conclusions: To be successful in enhancing EBP among newly graduated RNs, strategies need to incorporate both individually and organizationally directed factors.

New graduate nurses' developmental trajectories for capability beliefs concerning core competencies for healthcare professionals : A national cohort study on patient-centered care, teamwork and evidence-based practice.

Background: This study aimed to describe the developmental trajectories of registered nurses' capability beliefs during their first 3 years of practice. The focus was on three core competencies for health professionals-patient-centered care, teamwork, and evidence-based practice. Methods: A national cohort of registered nurses (n = 1,205) was recruited during their nursing education and subsequently surveyed yearly during the first 3 years of working life. The survey included 16 items on capability beliefs divided into three subscales for the assessment of patient-centered care, teamwork, and evidence-based practice, and the data were analyzed with linear latent growth modeling. Results: The nurses' capability beliefs for patient-centered care increased over the three first years of working life, their capability beliefs for evidence-based practice were stable over the 3 years, and their capability beliefs for teamwork showed a downward trend. Linking evidence to action: Through collaboration between nursing education and clinical practice, the transition to work life could be supported and competence development in newly graduated nurses could be enhanced to help them master the core competencies. Future research should focus on determining which factors impact the development of capability beliefs in new nurses and how these factors can be developed by testing interventions.

Design and use of mobile technology in distance language education : Matching learning practices with technologies-in-practice

This thesis focuses on the adaptation of formal education to people’s technology- use patterns, theirtechnology-in-practice, where the ubiquitous use of mobile technologies is central. The research question is: How can language learning practices occuring in informal learning environments be effectively integrated with formal education through the use of mobile technology? The study investigates the technical, pedagogical, social and cultural challenges involved in a design science approach. The thesis consists of four studies. The first study systematises MALL (mobile-assisted language learning) research. The second investigates Swedish and Chinese students’ attitudes towards the use of mobile technology in education. The third examines students’ use of technology in an online language course, with a specific focus on their learning practices in informal learning contexts and their understanding of how this use guides their learning. Based on the findings, a specifically designed MALL application was built and used in two courses. Study four analyses the app use in terms of students’ perceived level of self-regulation and structuration. The studies show that technology itself plays a very important role in reshaping peoples’ attitudes and that new learning methods are coconstructed in a sociotechnical system. Technology’s influence on student practices is equally strong across borders. Students’ established technologies-in-practice guide the ways they approach learning. Hence, designing effective online distance education involves three interrelated elements: technology, information, and social arrangements. This thesis contributes to mobile learning research by offering empirically and theoretically grounded insights that shift the focus from technology design to design of information systems.

The importance of considering the evidence in the MTP 2014 Amendment debate in India - unsubstantiated arguments should not impede improved access to safe abortion

With the objective to improve access to safe abortion services in India, the Ministry of Health and Welfare, with approval of the Law Ministry, published draft amendments of the MTP Act on October 29, 2014. Instead of the expected support, the amendments created a heated debate within professional medical associations of India. In this commentary, we review the evidence in response to the current discourse with regard to the amendments. It would be unfortunate if unsubstantiated one-sided arguments would impede the intention of improving access to safe abortion care in India.

Effects of computer reminders on complications of peripheral venous catheters and nurses' adherence to a guideline in paediatric care : a cluster randomised study

BACKGROUND: Reminder systems in electronic patient records (EPR) have proven to affect both health care professionals' behaviour and patient outcomes. The aim of this cluster randomised trial was to investigate the effects of implementing a clinical practice guideline (CPG) for peripheral venous catheters (PVCs) in paediatric care in the format of reminders integrated in the EPRs, on PVC-related complications, and on registered nurses' (RNs') self-reported adherence to the guideline. An additional aim was to study the relationship between contextual factors and the outcomes of the intervention. METHODS: The study involved 12 inpatient units at a paediatric university hospital. The reminders included choice of PVC, hygiene, maintenance, and daily inspection of PVC site. Primary outcome was documented signs and symptoms of PVC-related complications at removal, retrieved from the EPR. Secondary outcome was RNs' adherence to a PVC guideline, collected through a questionnaire that also included RNs' perceived work context, as measured by the Alberta Context Tool. Units were allocated into two strata, based on occurrence of PVCs. A blinded simple draw of lots from each stratum randomised six units to the control and intervention groups, respectively. Units were not blinded. The intervention group included 626 PVCs at baseline and 618 post-intervention and the control group 724 PVCs at baseline and 674 post-intervention. RNs included at baseline were 212 (65.4 %) and 208 (71.5 %) post-intervention. RESULTS: No significant effect was found for the computer reminders on PVC-related complications nor on RNs' adherence to the guideline recommendations. The complication rate at baseline and post-intervention was 40.6 % (95 % confidence interval (CI) 36.7-44.5) and 41.9 % (95 % CI 38.0-45.8), for the intervention group and 40.3 % (95 % CI 36.8-44.0) and 46.9 % (95 % CI 43.1-50.7) for the control. In general, RNs' self-rated work context varied from moderately low to moderately high, indicating that conditions for a successful implementation to occur were less optimal. CONCLUSIONS: The reminders might have benefitted from being accompanied by a tailored intervention that targeted specific barriers, such as the low frequency of recorded reasons for removal, the low adherence to daily inspection of PVC sites, and the lack of regular feedback to the RNs. TRIAL REGISTRATION: Current Controlled Trials ISRCTN44819426.

A modest start, but a steady rise in research use : A longitudinal study of nurses during the first five years in professional life

Background: Newly graduated nurses are faced with a challenging work environment that may impede theirability to provide evidence-based practice. However, little is known about the trajectory of registered nurses’ use ofresearch during the first years of professional life. Thus, the aim of the current study was to prospectively examinethe extent of nurses’ use of research during the first five years after undergraduate education and specifically assesschanges over time.Method: Survey data from a prospective cohort of 1,501 Swedish newly graduated nurses within the nationalLANE study (Longitudinal Analyses of Nursing Education and Entry in Worklife) were used to investigate perceiveduse of research over the first five years as a nurse. The dependent variables consisted of three single itemsassessing instrumental, conceptual, and persuasive research use, where the nurses rated their use on a five-pointscale, from ‘never’ (1) to ‘on almost every shift’ (5). These data were collected annually and analyzed bothdescriptively and by longitudinal growth curve analysis.Results: Instrumental use of research was most frequently reported, closely followed by conceptual use, withpersuasive use occurring to a considerably lower extent. The development over time showed a substantial generalupward trend, which was most apparent for conceptual use, increasing from a mean of 2.6 at year one to 3.6 atyear five (unstandardized slope +0.25). However, the descriptive findings indicated that the increase started onlyafter the second year. Instrumental use had a year one mean of 2.8 and a year five mean of 3.5 (unstandardizedslope +0.19), and persuasive use showed a year one mean of 1.7 and a year five mean of 2.0 (unstandardized slope+0.09).Conclusion: There was a clear trend of increasing research use by nurses during their first five years of practice.The level of the initial ratings also indicated the level of research use in subsequent years. However, it took morethan two years of professional development before this increase ‘kicked in.’ These findings support previousresearch claiming that newly graduated nurses go through a ‘transition shock,’ reducing their ability to useresearch findings in clinical work.

Facilitators and barriers to applying a national quality registry for quality improvement in stroke care

BACKGROUND: National quality registries (NQRs) purportedly facilitate quality improvement, while neither the extent nor the mechanisms of such a relationship are fully known. The aim of this case study is to describe the experiences of local stakeholders to determine those elements that facilitate and hinder clinical quality improvement in relation to participation in a well-known and established NQR on stroke in Sweden. METHODS: A strategic sample was drawn of 8 hospitals in 4 county councils, representing a variety of settings and outcomes according to the NQR's criteria. Semi-structured telephone interviews were conducted with 25 managers, physicians in charge of the Riks-Stroke, and registered nurses registering local data at the hospitals. Interviews, including aspects of barriers and facilitators within the NQR and the local context, were analysed with content analysis. RESULTS: An NQR can provide vital aspects for facilitating evidence-based practice, for example, local data drawn from national guidelines which can be used for comparisons over time within the organisation or with other hospitals. Major effort is required to ensure that data entries are accurate and valid, and thus the trustworthiness of local data output competes with resources needed for everyday clinical stroke care and quality improvement initiatives. Local stakeholders with knowledge of and interest in both the medical area (in this case stroke) and quality improvement can apply the NQR data to effectively initiate, carry out, and evaluate quality improvement, if supported by managers and co-workers, a common stroke care process and an operational management system that embraces and engages with the NQR data. CONCLUSION: While quality registries are assumed to support adherence to evidence-based guidelines around the world, this study proposes that a NQR can facilitate improvement of care but neither the registry itself nor the reporting of data initiates quality improvement. Rather, the local and general evidence provided by the NQR must be considered relevant and must be applied in the local context. Further, the quality improvement process needs to be facilitated by stakeholders collaborating within and outside the context, who know how to initiate, perform, and evaluate quality improvement, and who have the resources to do so.

Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings

Background: The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose. Methods: The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries. Results: The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge. Conclusions: Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs.

Knowledge translation in Uganda : a qualitative study of Ugandan midwives' and managers' perceived relevance of the sub-elements of the context cornerstone in the PARIHS framework

BACKGROUND: A large proportion of the annual 3.3 million neonatal deaths could be averted if there was a high uptake of basic evidence-based practices. In order to overcome this 'know-do' gap, there is an urgent need for in-depth understanding of knowledge translation (KT). A major factor to consider in the successful translation of knowledge into practice is the influence of organizational context. A theoretical framework highlighting this process is Promoting Action on Research Implementation in Health Services (PARIHS). However, research linked to this framework has almost exclusively been conducted in high-income countries. Therefore, the objective of this study was to examine the perceived relevance of the subelements of the organizational context cornerstone of the PARIHS framework, and also whether other factors in the organizational context were perceived to influence KT in a specific low-income setting. METHODS: This qualitative study was conducted in a district of Uganda, where focus group discussions and semi-structured interviews were conducted with midwives (n = 18) and managers (n = 5) within the catchment area of the general hospital. The interview guide was developed based on the context sub-elements in the PARIHS framework (receptive context, culture, leadership, and evaluation). Interviews were transcribed verbatim, followed by directed content analysis of the data. RESULTS: The sub-elements of organizational context in the PARIHS framework--i.e., receptive context, culture, leadership, and evaluation--also appear to be relevant in a low-income setting like Uganda, but there are additional factors to consider. Access to resources, commitment and informal payment, and community involvement were all perceived to play important roles for successful KT. CONCLUSIONS: In further development of the context assessment tool, assessing factors for successful implementation of evidence in low-income settings--resources, community involvement, and commitment and informal payment--should be considered for inclusion. For low-income settings, resources are of significant importance, and might be considered as a separate subelement of the PARIHS framework as a whole.